Section 245.240  Quality Improvement Program

a)         Each agency shall develop a quality improvement program for the agency.  The quality improvement program shall include written policies and shall evaluate the agency's total program at least once a year.  The evaluation shall, at a minimum, include a clinical or client record review, as appropriate.  This evaluation shall assess the extent to which the agency's program is appropriate, adequate, effective and efficient.  Results of the evaluation shall be reported to and acted upon by those responsible for the operation of the agency and shall be maintained separately as administrative records.

b)         Record Review.  At least quarterly, the agency shall review a sample of both active and closed clinical or client records to assure that established policies are followed in providing services (direct services, as well as those under contractual arrangement).  If applicable, this review shall include, but not be limited to:

1)         Whether the care plan was directly related to the stated diagnosis and plan of care;

2)         Whether the frequency of visits was consistent with the plan of care; and

3)         Whether the services could have been provided in a shorter span of time or with fewer visits.

c)         None of the information, interviews, reports, statements, memoranda and recommendations produced during or resulting from the agency's quality improvement program may be admissible as evidence nor discoverable in any action of any kind in any court, as provided in Article VIII, Part 21 of the Code of Civil Procedure (Medical Studies).

            (Source:  Added at 32 Ill. Reg. 8949, effective June 5, 2008)